Therapists, clients and sex: an ongoing ‘problem’

Sexual attraction, and in particular acting out of sexual desires in the context of psychotherapy, continues to be a problem within the domain of psychotherapy. In the following chapter, we seek to briefly set out the history and background of this phenomenon and illustrate using the contemporary discourse of a number of practising male therapists that the risks remain. In 1973, Kardener, Fuller, and Mensh surveyed physicians’ and psychiatrists’ experiences of erotic and non-erotic contact with patients. They found that 5% had had sex with patients. In 1979, Pope, Levenson, and Schover found 7% of psychologists conducting psychotherapy had had sexual contact with clients. Seven years later, Pope, Keith-Speigel, and Tabachnick (1986) conducted a similar survey and found that 95% of male psychotherapists questioned had been sexually attracted to clients. Further, 9.4% of those men had acted out those feelings. Eight years later, Rodolfa et al. (1994) reported an 88% attraction rate. Again, 4% of therapists questioned had acted out. Seto (1995) reported that complaints against psychologists in North America were on the rise, and in 2005, a third of a century after the Kardener et al. study (1973), Ladany et al. (1997) were still reporting some 5% of therapists admitting to sexual misconduct with patients.

But the problem of how to manage sexual attraction in psychotherapy goes right back to its origins. Breuer and Freud grappled with the implications of the obsession and infatuation of the former with Anna O (Breuer & Freud, 1895/1974). From that earliest moment, sexual attraction between analysands and analysts, labelled in the psychodynamic school as erotic transference and countertransference, was regarded as dangerous and problematic, a view crystallized by Freud (1915) in ‘Observations on Transference Love’, written in response to the increasingly widespread problem of therapists having sex with patients, a phenomenon that was arguably turning psychoanalysis into a laughing stock (Gay, 1995). Glen O. Gabbard, a formidable voice against sexual enactment in psychotherapy, relates the inappropriate sexual behaviour of such luminaries as Carl Jung, Otto Rank, Karen Horney and Frieda Fromm-Reichmann (Gabbard, 1994).

It seems that, despite paper after paper ringing alarm bells about sexual misconduct, almost nothing has changed. Acting out of sexual attraction seems to be still affecting between 1% and 5% of therapists, and inadequacies in training and supervision continue to be blamed (Halter, Brown, & Stone, 2007). Ladany et al. (1997), in reviewing literature on sexual attraction and acting out, note ‘the consistency of findings across these studies is impressive’ (p. 413).

We would argue that down the years, a number of discourses have been applied to the problem, all of which share the property of helping therapists minimize personal responsibility for inappropriate actions.

A failure of training

A prominent discourse calls for increased education and training; for instance, Edelwich and Brodsky (1982) and Pope et al. (1986) were critical of the lack of training and guidance on the management of sexual attraction. Rodolfa et al. (1994) (who provided a comprehensive review of such papers to that date) surveyed to see what had changed in training but found that almost nothing had. Five years later, Hamilton and Sprull (1999) were similarly critical of training. They suggested that systemic and pedagogic elements of training, notably the shift to briefer models, had reduced the concern over transference and countertransference. Training was not, they suggested, dealing adequately with the management of sexual attraction (although the moratorium on enactment was loud and clear) and supervision was found to be reluctant to deal honestly with trainees’ feelings. These criticisms are raised again and again down the years (Bartell & Rubin, 1990; Gilbert, 1987; McCarthy & Holliday, 2004; Noel, 2008; Wester & Vogel, 2002).

The client causes the problem

Freud started the ball rolling with discourse that attributed the problem of sexual enactment in therapeutic dyads to the female client. In Freud’s ‘Observations on Transference Love’ (1915), he recognizes that the phenomenon will ‘occur without fail’ (p. 383). However, the attraction, he points out, is not about the analyst and therefore is not something he should take pride in: the attraction belongs to the analytic situation, not to ‘the charms of his own person’. The analyst must be ‘proof against every temptation’ (Freud, 1915, p. 383), resisting the discomfort of not playing the traditional male role when a woman expresses her love as Sabbadini demonstrates in Chapter 9.

It’s not a problem after all …

As recently as 2001, Giovazolias and Davis found that more than half of the counselling psychologists who reported being sexually attracted to clients felt it had been beneficial to the therapy, but the team acknowledge that these respondents do have a vested interest in putting a positive spin on this. Only 6.3% of counselling psychologists reporting attraction felt it had a negative impact on therapy. Seven years earlier, only 43% of participants in the Rodolfa et al. study (1994) of US counselling psychologists reported sexual attraction as having a negative impact on therapy.

In fact, acting out may be a good thing

Down the years, attempts have been made to suggest that acting on sexual attraction may be a good thing. Sandor Ferenczi kissed his patients (Masson, 1988); heavyweight therapist William Reich made a case for sexual enactment as a therapeutic tool (Reich, 1968); and Glen Gabbard (1996) relates the sad tale of the fall from grace of an eminent psychiatrist who magically believed that sexual intercourse with him would prove salvific and so cure his patient.

A profile of the typical offender

Halter et al. (2007) summarize literature looking at factors associated with sexual misconduct by therapists. Wary of overvaluing ‘predictive’ profiling, they nonetheless draw out some broad conclusions. Offenders tend to be older males; victims tend to be female. Sexual misconduct is associated with the therapist having a history of being sexually abused. He may have suffered from insecure attachments, or lack current emotionally intimate relationships outside his job. And here, we would suggest, are some important clues as to why the institution of psychotherapy has been unable to put its house in order: perhaps this is not a professional problem but one associated with gender. Perhaps the problem lies in masculinity?

Masculinity

Masculinity is a menu of discourses that change from situation to situation. The menu offers hegemonic definitions, the prevailing ideal of a given institution that changes over time. Connell (1995) defines hegemonic masculinity as ‘the configuration of gender practice which embodies the currently accepted answer to the problem of the legitimacy of patriarchy, which guarantees the dominant position of men and the subordinate position of women’ (p. 77).

When worlds collide

Being constantly and unendingly produced through discourse, gender has no existential coherence. Identities are not settled and unitary, but rather, they shift constantly in talk, drawing upon cultural resources to make and remake identity in changing and fluid contexts. As they grow and develop, boys learn, and are taught, about their world and appropriate ways to be in that world. Levant (2001) describes how boys are taught, by reinforcement of approved behaviours and punishment of deviation, the culturally approved standards of masculinity. These standards come together in what Pollack and Levant (1998, p. 21) call a ‘code of masculinity’, which is defined to a large degree diametrically to feminine characteristics.

In developing their version of masculinity, men must make choices. Some choices men make may be automatic; others require active resolution of dilemmas, such as reconciling individual views and values about masculinity with the variations of masculinity prevalent in the immediate social and cultural context (Wetherell & Maybin, 1996). One key dilemma that men must solve, we would suggest, is conflict between masculinity and the demands of other social and cultural institutions in which they are situated, because, of course, masculinity is interwoven with other institutions that exert influence on its construction.

How to avoid falling to pieces

The psychoanalytic paradigm and ideas of the discursive construction of gender and sexuality share the idea of the subjective experience of a cohesive sense of self, struggling to maintain cohesion in the face of fragmentation. Both paradigms see the individual as a multivariously situated series of identities that are sourced from the world outside the body. In the discursive tradition, there are multiplicities of discourses that swirl in the cultural space, spoken by the individual who positions him or herself in relation to these discourses. The trick is to maintain the illusion of cohesion. Henriques, Hollway, Urwin, Venn, and Walkerdine (1984) suggest that key questions have to be asked in relation to the fragmented self: how are the fragments held together and how is subjective experience of continuity to be explained? Butler (1999) suggests that the production of gender lies in cultural codes circulating through language and that the performance of gender, by using these outer-world codes, gives the illusion of a cohesive self on the inside.

However, working as a therapist can present challenges to masculinity and with challenge comes the potential for fragmentation. Wester and Lyubelsky (2005) point out that men are expected to be warm and caring in the family (and of course, professional when working as therapists), a role that may have been internalized as feminine. O’Neil, Helms, Gable, David, and Wrightsman (1986, p. 335) named this switch between one role and another as ‘male gender role conflict’. Similarly, Adler (1927/1992) wrote of the ‘masculine protest’, the anxiety felt by men when they perceive themselves to be in a feminized position of weakness. Gough (2004) argues for a psychoanalytic understanding of masculinity, suggesting that such a reading can identify masculine anxieties and defences around the potential surfacing of feminine desires such as seeking (or perhaps giving) comfort. One defensive strategy he identifies is the reframing of powerful women (seen as such from disempowered masculine positions) as figures of ridicule. Similarly, Benwell (2003) suggests that dichotomous gender categories may be less about preserving patriarchy and more about constructing certainty and security.

Myriad discourses comprise the sense of self and we should be mindful of their existence in the background as we concentrate on the foreground discourses associated with masculinity and psychotherapy. Both these institutions are central to the constructions of identity that the research participants have in their professional context. When they work in harmony, or when opposing institutions are allied in different settings and at different times, the sense of self is secure: the problem comes when we have to be different people at the same time. Building on Davies and Harré’s (1990) insight that to experience contradictory positions challenges the sense of self as continuous and unitary, we would go further and suggest that the sense of threat is correlated to the centrality of the institutions to one’s sense of self, and that gender identity and professional identity are core identity markers for men.

Methodology

Eight male therapists who responded to a call for participants were interviewed online via email exchanges or synchronous ‘chatting’ in a secure chat room. Data were analyzed using a fusion of Foucauldian and critical discourse analyses. Foucauldian discourse analysis seeks to address issues of power and examines how the speaker (or writer) is positioned by discourse and how discourse reproduces power relations. Fusion of the ideas of Foucault with critical discourse analysis allowed focus on both the immediate conversational features and the wider dominant discourses underpinning meaning (see, e.g., Burman & Parker, 1993; Fairclough, 1992; Parker, 1992).

As analysis revealed discourses, each was named and the cultural and historical contexts in which they emerged were considered. It became possible to see how discourses could annex other discourses that enjoy power, to explore who might benefit from the discourse and to consider who might be disadvantaged by it.

Our arguments proceed on the basis that conscious experiencing of a simultaneous clash of identities brings a conflict in moral codes and expected behaviours. This clash of identities, we would suggest, stimulates moral anxiety predicated on the fear that masculine impulses could override professional codes, and that such a clash evokes particular anxiety when contemporary hegemonic constructs of masculinity – that permit sexual attraction, and potentially enactment thereof – clash contemporaneously with professional standards of restraint. It is our contention that the discourses spoken by participants in relation to sexual attraction are deployed to restore congruence between identities, and to minimize the sense of the self as fragmenting.

Interlude

Although you will only get the vaguest sense of the therapists who agreed to take part in this work from the extracts that we have space to offer, you should be assured that every single participant was seeking to make sense of experiences of sexual attraction that had, to a greater or lesser degree, caused them professional disquiet. They were, as men, striving to make sense of what had occurred: they were not seeking to be manipulative or to minimize the intensity of their experience. These are sincere men.

As to the reading we have made of their contributions, you may feel we have been somewhat harsh, even that we have exploited their honesty. We would make two observations. Firstly, discourses derived from the institution of psychotherapy had not provided these men with the explanations they sought. We would suggest that their honesty is exploited by our colluding with the notion that this institution can indeed provide such explanations. Secondly, it is important to hold onto the idea that it is the discourses that speak the man, and not vice versa. Participants speak of their experiences of sexual attraction using the discourses available to them. We would suggest that our duty of care is to highlight these discourses so these men can become empowered as to their effect. Our reading is therefore offered as an invitation to resist.

We believe that these men were bold in coming forward to talk about a contentious and almost taboo subject. We have therefore made great efforts to defend their anonymity. We provide only the most basic information about each participant, and any detail that might reveal, or even hint at, their identity has been changed. Extracts presented for your consideration are typical of discourses that occur over multiple contributions.

The discourse of physical attraction: rabbits in the headlights

When the participants first meet their clients, the attraction that occurs is apparently immediate, physical, places the male therapist in a passive position and is experienced as residing in the client. The therapists are like rabbits caught in the headlights of a car: passive, powerless to act, unable to look away.

Freddie’s picture is of a curvaceous blonde, but not one in tune with contemporary tastes, who is fat. She is attractive in a way that is firmly in tune with hegemonic masculinity. Freddie’s description of Lelia’s physique almost compels agreement that she is attractive to warrant one’s own sense of masculinity. Indeed, ‘she was a very sexy lady’ (not ‘I thought she was’). It is not that he found her to be attractive; she is, as a pre-existing state. So attractive is she that the effect, like the rabbit facing the oncoming car, is constructed as physically assaulting. Discourse used to describe sexual attraction often borrows from discourse of rape. Were Freddie’s words taken literally, he is describing an attack. Elsewhere in his discourses, he uses, in the context of Lelia’s attraction, such words and phrases as ‘intrude’, ‘intrusive’, ‘captivated’, ‘hooked in’. The imagery is explicitly used in Dominic’s account: he feels cast as the rapist and later, when his client gains agency, feels raped. The descriptors Freddie uses certainly place the attraction wholly within Lelia. She wears a business suit that emphasizes her power, but with a skirt rather than trousers, implying perhaps that she chooses to emphasize how attractive she is, thus shifting more responsibility for the attraction onto her. The imagery is from the world of Benny Hill and the Nuts photo-spread. ‘Saucy secretary’ changes Lelia’s status from the professional businesswoman implied when describing her clothes. The image suggests not only attractiveness, but the implied construction that she would be ‘game’ too: the saucy secretary is not a prudish image. Arthur treads a similar path:

Related posts:

Acknowledgements I: Relational Perspectives on Sexual Attraction in Therapy The Role of Psychological Proximity and Sexual Feelings in Negotiating Relatedness in the Consulting Room: A Phenomenological Perspective An Acceptance Commitment Therapy Approach to Sexual Attraction Sexual Attraction in Conjoint Couple Therapy Index

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